Nokea
A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
- A. Prevent the development of acute respiratory failure
- B. Decrease cerebral blood flow
- C. Increase systemic tissue perfusion
- D. Prevent cerebral anoxia
Correct Answer: B
Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.
You may also like to solve these questions
Which of the following would be considered a sensible type of fluid loss?
- A. sweat
- B. respiratory excretions
- C. vomit
- D. water loss in feces
Correct Answer: A
Rationale: Sensible fluid loss is measurable, such as sweat or urine. Respiratory excretions, vomit, and fecal water loss are insensible (not easily measured).
A transient homeless client with a history of mental illness and substance abuse is to be discharged. Which of the following support systems are most likely to provide social support for the client? Select all that apply.
- A. Self-help programs.
- B. Internet-based programs.
- C. Community agencies.
- D. Governmental agencies.
- E. Friends.
- F. Family.
Correct Answer: A,C,D
Rationale: Community agencies (C), governmental agencies (D), and self-help programs (A) are likely to provide social support for a homeless client with mental illness and substance abuse. Internet-based programs (B), friends (E), and family (F) may be less accessible or reliable.
When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:
- A. Drainage on the surgical dressing
- B. Complaints of neck pain
- C. Bleeding from the mouth
- D. Swelling in the posterior neck
Correct Answer: D
Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.
A client with breast cancer is returned to the room following a right total mastectomy. The nurse should:
- A. Elevate the client's right arm on pillows
- B. Place the client's right arm in a dependent sling
- C. Keep the client's right arm on the bed beside her
- D. Place the client's right arm across her body
Correct Answer: A
Rationale: Elevating the arm on pillows reduces edema and promotes lymphatic drainage post-mastectomy, aiding recovery.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.